The Deadly Choices at Memorial

The smell of death was overpowering the moment a relief worker cracked open one of the hospital chapel’s wooden doors. Inside, more than a dozen bodies lay motionless on low cots and on the ground, shrouded in white sheets. Here, a wisp of gray hair peeked out. There, a knee was flung akimbo. A pallid hand reached across a blue gown.

Within days, the grisly tableau became the focus of an investigation into what happened when the floodwaters of Hurricane Katrina marooned Memorial Medical Center in Uptown New Orleans. The hurricane knocked out power and running water and sent the temperatures inside above 100 degrees. Still, investigators were surprised at the number of bodies in the makeshift morgue and were stunned when health care workers charged that a well-regarded doctor and two respected nurses had hastened the deaths of some patients by injecting them with lethal doses of drugs. Mortuary workers eventually carried 45 corpses from Memorial, more than from any comparable-size hospital in the drowned city.

Investigators pored over the evidence, and in July 2006, nearly a year after Katrina, Louisiana Department of Justice agents arrested the doctor and the nurses in connection with the deaths of four patients. The physician, Anna Pou, defended herself on national television, saying her role was to ‘‘help’’ patients ‘‘through their pain,’’ a position she maintains today. After a New Orleans grand jury declined to indict her on second-degree murder charges, the case faded from view.

In the four years since Katrina, Pou has helped write and pass three laws in Louisiana that offer immunity to health care professionals from most civil lawsuits — though not in cases of willful misconduct — for their work in future disasters, from hurricanes to terrorist attacks to pandemic influenza. The laws also encourage prosecutors to await the findings of a medical panel before deciding whether to prosecute medical professionals. Pou has also been advising state and national medical organizations on disaster preparedness and legal reform; she has lectured on medicine and ethics at national conferences and addressed military medical trainees. In her advocacy, she argues for changing the standards of medical care in emergencies. She has said that informed consent is impossible during disasters and that doctors need to be able to evacuate the sickest or most severely injured patients last — along with those who have Do Not Resuscitate orders — an approach that she and her colleagues used as conditions worsened after Katrina.

Pou and others cite what happened at Memorial and Pou’s subsequent arrest — which she has referred to as a "personal tragedy" — to justify changing the standards of care during crises. But the story of what happened in the frantic days when Memorial was cut off from the world has not been fully told. Over the past two and a half years, I have obtained previously unavailable records and interviewed dozens of people who were involved in the events at Memorial and the investigation that followed.

The interviews and documents cast the story of Pou and her colleagues in a new light. It is now evident that more medical professionals were involved in the decision to inject patients — and far more patients were injected — than was previously understood. When the names on toxicology reports and autopsies are matched with recollections and documentation from the days after Katrina, it appears that at least 17 patients were injected with morphine or the sedative midazolam, or both, after a long-awaited rescue effort was at last emptying the hospital. A number of these patients were extremely ill and might not have survived the evacuation. Several were almost certainly not near death when they were injected, according to medical professionals who treated them at Memorial and an internist’s review of their charts and autopsies that was commissioned by investigators but never made public.

In the course of my reporting, I went to several events involving Pou, including two fund-raisers on her behalf, a conference and several of her appearances before the Louisiana Legislature. Pou also sat down with me for a long interview last year, but she has repeatedly declined to discuss any details related to patient deaths, citing three ongoing wrongful-death suits and the need for sensitivity in the cases of those who have not sued. She has prevented journalists from attending her lectures about Katrina and filed a brief with the Louisiana Supreme Court opposing the release of a 50,000-page file assembled by investigators on deaths at Memorial.

The full details of what Pou did, and why, may never be known. But the arguments she is making about disaster preparedness — that medical workers should be virtually immune from prosecution for good-faith work during devastating events and that lifesaving interventions, including evacuation, shouldn’t necessarily go to the sickest first — deserve closer attention. This is particularly important as health officials are now weighing, with little public discussion and insufficient scientific evidence, protocols for making the kind of agonizing decisions that will, no doubt, arise again.

At a recent national conference for hospital disaster planners, Pou asked a question: ‘‘How long should health care workers have to be with patients who may not survive?’’ The story of Memorial Medical Center raises other questions: Which patients should get a share of limited resources, and who decides? What does it mean to do the greatest good for the greatest number, and does that end justify all means? Where is the line between appropriate comfort care and mercy killing? How, if at all, should doctors and nurses be held accountable for their actions in the most desperate of circumstances, especially when their government fails them?

A Shelter From the Storm

Memorial Medical Center was situated on one of the low points in the bowl that is New Orleans, three miles southwest of the city’s French Quarter and three feet below sea level. The esteemed community hospital sprawled across a neighborhood of double-shotgun houses. Several blocks from a housing project but a short walk to the genteel mansions of Uptown, it served a diverse clientele. Built in 1926 and known for decades as Southern Baptist, the hospital was renamed after being purchased in 1995 by Tenet Healthcare, a Dallas-based commercial chain. For generations, the hospital’s sturdy walls served as a shelter when hurricanes threatened: employees would bring their families and pets, as well as coolers packed with muffulettas.

By the time Katrina began lashing New Orleans in the early hours of Monday, Aug. 29, some 2,000 people were bunking in the hospital, including more than 200 patients and 600 workers. When the storm hit, patients screamed as windows shattered under a hail of rocks from nearby rooftops. The hospital groaned and shook violently.

At 4:55 a.m., the supply of city power to the hospital failed. Televisions in patient rooms flicked off. But Memorial’s auxiliary generators had already thumped to life and were humming reassuringly. The system was designed to power only emergency lights, certain critical equipment and a handful of outlets on each floor; the air-conditioning system shut down. By that night, the flooding receded from the surrounding streets. Memorial had sustained damage but remained functional. The hospital seemed to have weathered one more storm.

The Evacuation Begins

Anna Pou was a 49-year-old head- and neck-cancer surgeon whose strong work ethic earned respect from doctors and nurses alike. Tiny and passionate, with coiffed cinnamon hair and a penchant for pearls, Pou was funny and sociable, and she had put her patients at the center of her life.

The morning after Katrina hit, Tuesday, Aug. 30, a nurse called to Pou: ‘‘Look outside!’’ What Pou saw from the window was hard to believe: water gushing from the sewer grates. Other staff members gaped at the dark pool of water rimmed with garbage crawling up South Claiborne Avenue in the direction of the hospital.

Senior administrators quickly grasped the danger posed by the advancing waters and counseled L. René Goux, the chief executive of Memorial, to close the hospital. As at many American hospitals in flood zones, Memorial’s main emergency-power transfer switches were located only a few feet above ground level, leaving the electrical system vulnerable. ‘‘It won’t take much water in height to disable the majority of the medical center,’’ facilities personnel had warned after Hurricane Ivan in 2004. Fixing the problem would be costly; a few less-expensive improvements were made.

Susan Mulderick, a tall, no-nonsense 54-year-old nursing director, was the rotating ‘‘emergency-incident commander’’ designated for Katrina and was in charge — in consultation with the hospital’s top executives — of directing hospital operations during the crisis. The longtime chairwoman of the hospital’s emergency-preparedness committee, Mulderick had helped draft Memorial’s emergency plan. But the 246-page document offered no guidance for dealing with a complete power failure or for how to evacuate the hospital if the streets were flooded. Because Memorial’s chief of medical staff was away, Richard Deichmann, the hospital’s soft-spoken medical-department chairman, organized the physicians.

At 12:28 p.m., a Memorial administrator typed ‘‘HELP!!!!’’ and e-mailed colleagues at other Tenet hospitals outside New Orleans, warning that Memorial would have to evacuate more than 180 patients. Around the same time, Deichmann met with many of the roughly two dozen doctors at Memorial and several nurse managers in a stifling nurse-training room on the fourth floor, which became the hospital’s command center. The conversation turned to how the hospital should be emptied. The doctors quickly agreed that babies in the neonatal intensive-care unit, pregnant mothers and critically ill adult I.C.U. patients would be at great risk from the heat and should get first priority. Then Deichmann broached an idea that was nowhere in the hospital’s disaster plans. He suggested that all patients with Do Not Resuscitate orders should go last.

A D.N.R. order is signed by a doctor, almost always with the informed consent of a patient or health care proxy, and means one thing: A patient whose heartbeat or breathing has stopped should not be revived. A D.N.R. order is different from a living will, which under Louisiana law allows patients with a ‘‘terminal and irreversible condition’’ to request in advance that ‘‘life-sustaining procedures’’ be withheld or withdrawn.

But Deichmann had a different understanding, he told me not long ago. He said that patients with D.N.R. orders had terminal or irreversible conditions, and at Memorial he believed they should go last because they would have had the ‘‘least to lose’’ compared with other patients if calamity struck. Other doctors at the meeting agreed with Deichmann’s plan. Bill Armington, a neuroradiologist, told me he thought that patients who did not wish their lives to be prolonged by extraordinary measures wouldn’t want to be saved at the expense of others — though there was nothing in the orders that stated this. At the time, those attending the meeting didn’t see it as a momentous decision, since rescuers were expected to evacuate everyone in the hospital within a few hours.

There was an important party missing from the conversation. For years, a health care company known as LifeCare Hospitals of New Orleans had been leasing the seventh floor at Memorial. LifeCare operated a ‘‘hospital within a hospital’’ for critically ill or injured patients in need of 24-hour care and intensive therapy over a long period. LifeCare was known for helping to rehabilitate patients on ventilators until they could breathe on their own. LifeCare’s goal was to assist patients until they improved enough to return home or to nursing facilities; it was not a hospice.

The 82-bed unit credentialed its own doctors, most of whom also worked at Memorial. It had its own administrators, nurses, pharmacists and supply chain. It also had its own philosophy: LifeCare deployed the full array of modern technology to keep alive its often elderly and debilitated patients. Horace Baltz, one of the longest-serving doctors at Memorial, told me of spirited debates among doctors over coffee about what some of his colleagues considered to be excessive resources being poured into hopeless cases. ‘‘We spend too much on these turkeys,’’ he said some would say. ‘‘We ought to let them go.’’

Many of the 52 patients at LifeCare were bedbound or required electric ventilators to breathe, and clearly, they would be at significant risk if the hospital lost power in its elevators. The doctors I spoke to who attended the meeting with Deichmann did not recall discussing evacuating LifeCare patients specifically, despite the fact that some of the doctors at the meeting worked with both Memorial and LifeCare patients.

In the afternoon, helicopters from the Coast Guard and private ambulance companies began landing on a long-unused helipad atop an eight-story parking garage adjacent to the hospital. The pilots were impatient — thousands of people needed help across the city. The intensive-care unit on the eighth floor rang out with shouts for patients: ‘‘We need some more! Helicopters are waiting!’’

A crew of doctors, nurses and family members carried Memorial patients down flights of stairs and wheeled them to the hospital wing where the last working elevator brought them to the second floor. Each patient was then maneuvered onto a stretcher and passed through a roughly three-by-three-foot opening in the machine-room wall that offered a shortcut to the parking garage. Many patients were placed in the back of a pickup truck, which drove to the top of the garage. Two flights of metal steps led to the helipad.

At LifeCare that afternoon, confusion reigned. The company had its own ‘‘incident commander,’’ Diane Robichaux, an assistant administrator who was seven months pregnant. At first everything seemed fine; Robichaux established computer communications with LifeCare’s corporate offices in Texas and was assured that LifeCare patients would be included in any FEMA evacuation of Memorial. But as the day wore on, the texts between LifeCare staff members and headquarters grew frantic as it became clear that the government’s rescue efforts and communications were in chaos.

According to the messages, Robichaux asked Memorial administrators to add her 52 patients to transport plans being organized with the Coast Guard. An executive at the hospital told Robichaux that permission would be requested from Memorial’s corporate owner, Tenet Healthcare. ‘‘I hope and pray this is not a long process for getting their approval,’’ Robichaux said in an e-mail message to her colleagues at headquarters. (A Tenet spokesman, David Matthews, wrote me in an e-mail message that LifeCare staff members turned down several offers of evacuation assistance from Memorial staff members on Tuesday afternoon.)

The doctors had now spent days on duty, under stress and sleeping little. Ewing Cook, one of the hospital’s most senior physicians, told me that he decided that in order to lessen the burden on nurses, all but the most critical treatments and care should be discontinued. When Bryant King, a 35-year-old internist who was new to Memorial, came to check on one of his patients on the fourth floor, he canceled the senior doctor’s order to turn off his patient’s heart monitor. When Cook found out, he was furious and thought that the junior doctor did not understand the circumstances. He directed the nurse to reinstate his instructions.

It was dark when the last of the Memorial patients who had been chosen for immediate evacuation were finally gone. Later that night, the Coast Guard offered to evacuate more patients, but those in charge at Memorial declined. The helipad had minimal lighting and no guard rail, and the staff needed rest.

Memorial had shaved its patient census from 187 to about 130. On the seventh floor, all 52 LifeCare patients remained, including seven on ventilators. ‘‘Been on the phone with Tenet,’’ a LifeCare representative outside the hospital wrote to Robichaux. ‘‘Will eventually be to our patients. Maybe in the morning.’’

Fateful Triage Decisions

At about 2 a.m. on Wednesday, Aug. 31 — nearly 48 hours after Katrina made landfall near New Orleans — Memorial’s backup generators sputtered and stopped. Ewing Cook later described the sudden silence as the ‘‘sickest sound’’ of his life. In LifeCare on the seventh floor, critically ill patients began suffering the consequences. Alarm bells clanged as life-support monitors and ventilators switched to brief battery reserves while continuing to force air into the lungs of seven patients. In about a half-hour, the batteries failed and the regular hiss of mechanical breaths ceased. A Memorial nurse appeared and announced that the Coast Guard could evacuate some critical patients if they were brought to the helipad immediately. Volunteers began carrying the LifeCare patients who relied on ventilators down five flights of stairs in the dark.

A LifeCare nurse navigated the staircase alongside an 80-year-old man on a stretcher, manually squeezing air into his lungs with an Ambu bag. As he waited for evacuation on the second floor, she bagged him for nearly an hour. Finally a physician stopped by the stretcher and told her that there was no oxygen for the patient and that he was already too far gone. She hugged the man and stroked his hair as he died.

Anna Pou began bagging another patient on the second floor to relieve a nurse whose hands were growing tired. That patient, along with two other LifeCare patients who relied on ventilators, also died early that morning, but the others were evacuated by helicopter. The hospital chaplain opened a double door with stained-glass windows down the hallway, and the staff began wheeling bodies into the chapel. Distraught nurses cried, and the chaplain held them and prayed with them.

The sun rose and with it the sultry New Orleans temperature, which was on its way to the mid-90s. The hospital was stifling, its walls sweating. Water had stopped flowing from taps, toilets were backed up and the stench of sewage mixed with the odor of hundreds of unwashed bodies.

Visitors who had come to the hospital for safety felt so desperate that they cheered when two airboats driven by volunteers from the Louisiana swamplands roared up to the flooded emergency-room ramp. The flotilla’s organizers, Mark and Sandra LeBlanc, had a special reason to come to Memorial: Vera LeBlanc, Mark’s 82-year-old mother, was at LifeCare, recovering from colon-cancer surgery. Sandra, an E.M.T., knew that her mother-in-law couldn’t swallow, so she was surprised when she saw that Vera and other patients who needed IVs to keep hydrated were no longer getting them. When her husband asked a Memorial administrator why, the administrator told him that the hospital was in survival mode, not treating mode. Furious, Mark LeBlanc asked, ‘‘Do you just flip a switch and you’re not a hospital anymore?’’

22 comments

I just don’t understand this type of decision making. I am not a medical professional, nor am I here to judge. However, I don’t understand the logic behind evacuating the sickest patients last. I would think that they would get top priority. No matter how I look at this, the reasoning seems illogical…

While our deeper human compassion might suggest to us that the most in need, the most sick, should be rescued first, the reality is very different for good reasons. Those most likely to survive the trip (i.e. the ‘most well’) get first priority so that the very limited resources involved in a rescues are used on a greater number. Those who find themselves at the end of such a triage are in further diminishing categories of survivability. International triage standards for any mass casualty situation (think bombing, train crash, etc) is to not focus on the most heavily injured but on those most likely to survive with as little as possible intervention from the 1st responder. To have it any other way would mean, for example, that a responder might be ‘stuck’ performing CPR etc on someone not likely to survive when they could be using their training towards helping the 10 other victims with less-life threaten injuries.

As we have further distanced ourselves from death in this society, few who read this article have see the very tail end of what we call ‘life’: heavy machinery, constant supervision, lack of mobility, electricity…all things which quickly become near-impossible to secure resources during a disaster on the scale of Katrina. We may all derive some small comfort from the fact that most hospitals are well equipped to handle disaster (in fact, full evacuation is almost unheard of for a medical facility pre-Katrina for good reason) but that doesn’t ease the disease we have when we hear of such utterly heartbreaking ethical decisions.

My elderly father had been a dues-paying member of a famous HMO for 40 years when he broke his hip. The Triage Nurse denied him access to the HMO’s hospital. Two days later he died. This was NOT any kind of emergency situation like Katrina. As a society we should become more honest in our discussions and debates about how the medical community is actually treating our elderly.

A tragic situation like Katrina simply does not relieve caregivers of the obligation to follow the law. The deliberate ending of the life of a patient is a criminal act. Instead of changing the law to grant an exception for medical personnel in disasters, existing law should be enforced. For prosecutors to refuse to present their strongest witnesses is tantamount to dereliction of duty. If the account in this story is true, there seems little alternative but to release the 50,000 pages of evidence and to pursue a federal criminal prosecution.

What would have happened if all of the healthcare professionals had walked away to save their own families as one physician did? Did he face prosecution? NO.

Although this article is heart wrenching, people who were there will (unconsciously) nuance their stories to justify their own actions of their participation in that event. That is normal human behavior.

I am curious if those who want prosecution of those arrested from Memorial are also seeking prosecution of those who authorized torture of detainees on foreign soil.

From the comfort of an armchair, it is easy to pronounce judgement, but for those who were directly and intimately involved, I am betting they have their own misgivings (what could I have done better or different) and are working to assure that their own nightmare never has to be contemplated by others.

Should the citizens of NewOrleans be suing the state or FEMA for leaving them at the Civic Center or moving them to a highway without food/water, taking them to the airport and abandoning them there? Must we always seek retribution for perceived wrongs against us?

I don’t have all the answers, but at least I do have questions. I don’t condone any of the negative occurrences post Katrina, but prosecuting one physician does not seem to be the answer either.

As a nurse in a neuro intensive care, where many of our patients are admitted with catastrophic brain injury, I have hastened the deaths of patients by pharmaceutical means to provide comfort to them after life support is withdrawn. I have even gone so far as to hasten a death this way to provide comfort for a grieving spouse when I was sure that the patient couldn’t possibly have any subjective experience of discomfort, but the appearence of their death was torture for the surviving spouse. I am comfortable with hastening death where appropriate. I cannot fathom administering a lethal cocktail to someone who can talk to me while I’m doing so, even if they consented to the death, much less as a covert act of so-called mercy.

My moral outrage, however, coexists uneasily with an understanding of how hard being a physician or nurse is under ideal circumstances. I cannot imagine trying to do it without electricity or other essential resources for days on end, with no sense of when the ordeal would end.

I guess I could forgive abandoning the patients until or unless more help was forthcoming. This too goes against my professional code of ethics, but it’s preferable to the grisly alternative.

Is this the kind of work ProPublica plans to bring us? An insipidly narrow and cynical indictment of doctors trying to do the right thing? Little public good will emerge from this story. Doctors will become even more fearful of legal action than they already are, prompting them to order more futile, defensive measures for terminally ill patients and further driving up health care costs. Is the point of this story, to further bankrupt our health care system?

Also, one has to consider the tactics of the reporter. Surely many of the doctors and nurses who spoke most frankly about end-of-life care would never have done so had they known Fink was intent on a hit piece. It seems unavoidable that she misrepresented the angle of the story to her sources.

To read this account, suboptimal as so many people refused to talk to the reporter, can have you shudder at the thought of what this must have been like.

Too bad that there couldn’t be some broad immunity for everyone, a fund established to pay out any civil claims decided, so that EVERYBODY involved could give full testimony as to what happened. What happened and why needs to be fully explored and analyzed so that the appropriate logistical and ethical lessons can be learned. Instead it degenerated into a legal/bureaucratic/PR/civil suit morass.

If you are forced to leave a patient ..(though in this case a lot of the racist fear and hysteria was whipped up needlessly)...

And the patient will suffer and die a horrible death unattended…

Can there then be a pro-active form of palliative care when one if forced by circumstances to act in a way that ensures future suffering doesn’t occur…but the immediate goal then becomes the death of the patient. ??

And, when this decision is made for a large number of patients, can then “the task” get away from your ethical center—such that one doesn’t see the trees for the forest? A slippery slope where crossing the Rubicon without clear boundaries cascades?

We’ve all seen war movies (OK some of us) where a horribly injured soldier on the battlefield is shot by his comrades in order to alleviate the suffering. We don’t call it murder.

On the one hand, as I read this, I did try to put myself in the shoes of the staff: utterly squalid conditions that were unlike anything they had ever encountered, lack of sleep, misinformation, fear, and yes, barely contained biases (Dr. Thiele?), all of which together hindered effective decision making. I think, given the complete failure of civil government at all levels during hurricane Katrina, it would have been inappropriate to single her out, or those who worked with her.

And yet, I am deeply disquieted by Dr. Pou’s determined effort to “rehabilitate” herself and to immunize her own decision making not just from the law, but from public opinion. Her efforts then and now have to be viewed in light of some other factors:

Why did these doctors feel they had the right to assume control and shut out others like Dr. King, with less radical ideas?

What possible justification did they have for trying to prevent people from rescuing their own family members under circumstances that were as extreme as they now claim?

Why didn’t these doctors make an effort to take sleeping shifts so that they could operate at a higher level at other times?

Why were staff who were willing to stay told they had to leave?

Even to a layperson, Dr. Pou’s decision to view a DNR order as determinative is an inappropriate shortcut to making an actual, informed decision.

As I read this, I kept thinking of Dr. Pou as the character in “The Fall/La Chute” by Albert Camus: having faced an ethical challenge, her real failing is to continue to defend and protect herself rather than to understand the inadequacy of her own response, however understandable at the time, and try to make sure she or others like her don’t have to face such awful circumstances in the future.

Sorry, Dr. Pou, however difficult it might have been, I am certain I don’t want you taking care of me or anybody I love. Your streak of self-rationalization runs to deep.

I am a physician who was at another hospital in Orleans Parish during Katrina. Though I and the others at my hospital where also faced with dire circumstances, the experience was entirely different. Medical care continued, the hospital had clear leadership, and even family members and non-staff pitched in to get the job done.

I am horrified at the actions of many of the physicians at Memorial Hospital described in this story. Public opinion in New Orleans has always been on the side of the healthcare providers in this story, but I cannot condone—in any circumstance—the active administration of medications intended to cause death.

I think the police hold some responsibility for ordering everyone out by 5 p.m., ordering the impossible. If they were informed of the circumstances then they were in fact ordering these people to abandon these patients alive.

Martial law had not been declared so it doesn’t seem the police had any position to give such an order. They could have strongly recommended yes but to order the patients to be abandoned and to say that they would not protect the medical staff and patients inside from civil unrest? No. The civil suit should be put on the police.

Question #1. Were the police informed of the situation before they ordered the hospital to be abandon?

Plus, with a near empty hospital and intermittent gunfire outside the building, they had a wide array of objects to block all doors and stairways with to secure for one more night. Plus it is said in the story that L. René Goux the chief executive of the hospital distributed guns to security and maintenance staff without any reference to where the guns came from.

Question #2. If the guns didn’t then arrive from an outside source, just what is Goux doing with so many guns, a weapons cache at a hospital? If this is common for hospitals doesn’t that make the hospital, staff and patients a target for a criminal takeover and a mass kill with their own guns or an outright hostage situation?

Question #3. What is Dr. Ewing Cook, a senior physician at the hospital doing carrying a handgun? Isn’t that antithetical to the principles of a doctor to not inflict harm in the event of the Hippocratic Oath? Some doctors don’t take that oath since it isn’t a requirement anyway so whether Cook did or not is unknown to me.

The saddest part for me is, had I been there these people would have been at the helipad even if the heaviest was 350 pounds. Explaining that is a matter of grade school science class and a last stoke of whatever food and water is left for the final haul. If that is all gone then even a shot of amphetamine from the doc would have been better than nothing. Had they died then it would have been for lack of a helicopter instead of a lack of knowledge of how to move heavy things and even more so with gravity doing most of the work.

These patients were left behind dead so the most compelling question of all for me is, considering that these people were literally exhausted and could not go on which is why they did what they did, when the morgue detail arrived the story said that all these people on the 7th floor were down there in the chapel.

Question #4. Now, how did the dead get down 7 flights of stairs to be the chapel after the medical staff had left?

As this is a forum for offering comment and opinion, here are mine: I agree and disagree.

I agree that Dr Pou, Ms Landry and Ms Budo are not the only ones culpable, but if the Nuremburg defense was not viable then, it is no more viable now: doing what one has been told or what was “suggested” is still a matter of criminality. If anything, this investigation shows that the culpability was a bit more widespread and complicated than at first believed, and the original source of the idea should also be held responsible. Also, the person who “managed” this emergency should be cited for the poor organization of emergency response that allowed people to be in such straits that they even considered this as a correct choice. There were some excellent suggestions above, and thank goodness we have better plans and preparation now.

I can’t even begin to imagine the breakdown in character that is necessary to sacrifice the lives of others to save yourself, especially if that is in direct contradiction to the ethics of your chosen profession. And I’m sorry, but the CMH usually goes to the soldier who either put his own life at risk to save others or sacrificed himself to save his comrades, not the man who regrettingly pulls the trigger on his fallen. Giving the man a grenade or leaving him with a gun at least gives him a choice, but I could argue this point when it is tangential, at best.

These folks were not offered a choice; I’m willing to bet, however, that if presented with it, THEY at least would have been more willing than their caregivers to sacrifice themselves for the “Greater Good”.

Dr Pou’s question about how long should a care provider stay with a terminal patient? Until the end, and only until the naturally occurring end.

The thing is, Dr Pou, you don’t know when that will be. No one on earth knows. And no matter how you choose to end your own pain and confusion over this matter, you cannot stand in what you did and call it right. Learning from a mistake requires owning it.

For those of you who disagree with me, that is your right. Kindly announce that to me before I agree to be your patient, if you are a health care provider, and I will be happy to find someone else who is more in line with my ethics. I would rather do that than attempt retribution when you fail to live up to my expectations. I am not litigious; lawsuits don’t undo the past, they just give some folks hesitation that doesn’t need to be there.

See, I expect you (even a doctor) to be human, and I expect you to make mistakes. But I also expect you to do everything you can to save my life, as my care giver, and not make as your purpose to end my life for your convenience.

I am not a doctor, and it may be that you will doubt what I have to say next. That is all right; I can’t make this palatable to everyone.

I am a mother, and I am a protector. When the situation calls for it, I am a warrior. I would not leave these patients and would face down ANYONE who dared to tell me that I should. I would not allow anyone to administer a lethal dose of anything to anyone in my care. I would be the last the leave the hospital, not my patients. Triage would also demand, I should think, that those in immediate danger of loss of life get immediate care, and that those who aren’t “as sick”, as long as they are stable, can remain so until another patient’s crisis has passed. It’s not rocket science—its prioritization based on what you’re commmitted to do.

It isn’t a matter of circumstance or condition, backed up toilets, lack of sleep, poor planning, fatigue or malnourishment. It’s a matter of integrity, and how well you back up your integrity with your will. To allow anything else to be a determinant is a lie.

My hat’s off to the physician who realized in retrospect that he shouldn’t have left when he did; he at least realized what he did, and probably won’t repeat it.

If this article, or this comment, offends you, remember—reading it or subscribing to this service, is an optional activity.

As far as the story goes he was a paraplegic in his legs and not his arms since he fed himself breakfast, was talkative and aware of his surroundings and in good spirits, miserably uncomfortable like everyone else but not dying of anything and was not recovering from surgery since he had been operated on yet.

He was chosen to die because of his weight and I think that was unnecessary and unacceptable. Given a wheelchair his status was probably ambulatory but was assigned as a 3.

He had use of his arms so there was no harm in telling him anywhere between 5 pm and 9 pm (staff left) the facts of the situation, and leaving him with a couple of guns and ammunition so that he would have a fighting chance in the event any of the rouges outside the hospital got in there and sadly, in a worst case scenario would have had the means to end his own life, of which if I was the doctor, would be a far better alternative than a homicide charge on me.

It is said that Emmett Everett even pleaded for his life, “Don’t let them leave me behind.” That would have been enough for me to engage to Coast Guard to try and help get him out of there.

Being told that I imagine myself as Emmett Everett and what I might have said, “I understand, you guys are exhausted and I weigh 380 pounds. When the helicopter arrives please ask the Coast Guard guys who are strong soldiers and not exhausted to help get me out of here.”

If I were the doctor I would have done just that and if the Coast Guard refused I again would have offered Emmett Everett a couple guns and ammo to hold him until the Coast Guard can get back with a couple guys to get him out of there.

That’s why I think there is or was no rhyme or reason for Emmett Everett’s death since he could have held his own until morning.

Question #1. Was any intention to kill Emmett Everett put off until the last minute and euthanized after the Coast Guard was asked to help get him out but refused or did they entirely skip asking the Coast Guard to help in getting him out, taking it for granted that the Coast Guard would say no anyway and euthanized him?

Question #2. Was Everett told of the situation and offered any food/water, guns and ammo to hold him alone until the next day on the premise that the Coast Guard would be informed of his presence and would be back in the morning with more help.

Question #3. Would the Coast Guard have helped get Everett off the 7th floor and onto the chopper if they had been asked to?

A few points. Comparing Dr. Pou’s defense to the one at Nuremberg (“I was just following orders”) is a bit much. What happened at New Orleans was not the outgrowth of some underlying philosophy or genocidal mindset (like Germany, Sudan, Rawanda, Bosnia, etc.). The healthcare clinicians were put in a very difficult and unexpected situation. A lack of command, bad decisions snowballing down slippery slopes, etc.

While I admire the job the reporter did it is also patently clear so many people declined to be interviewed such that I don’t think we still have the whole truth…or enough to really come to an informed analysis of what went wrong.

Instead the convoluted and torturous plot goes on…Murder charges filed, murder charges dropped, Dr. Pou wins PR war, then Dr. Pou loses PR war, civil suits languish in court over the years. Ten years from now someone writes a fairly comprehensive book about it. Most people say “what is that about?”.

Dr. Pou and the nurses were charged with murder. They fought back legally and from a PR angle. As described in the article they won the legal fight, but still have PR issues and civil suits pending.

I participate in some Disaster Preparedness email groups. There are discussions about triage if a severe and deadly pandemic strikes—-should we take patients off ventilators who are very sick and almost certainly going to die anyway in order to use them on a patient who might be saved and has a better chance of recovery with a meaningful quality of life? Imagine the ICU is filled with patients on ventilators fitting the following profile——90 year old post cardiovascular surgery for CABG and AVR, with heart failure, renal failure, kidney failure. being evaluated for obviously marked neurologic defects. Wealthy patient and family who have insisted “everything be done” because “he’s a fighter”.

Meanwhile down in the ER a bunch of flu victims are being intubated and need to be moved to the ICU and be placed on ventilators. Many of them are undocumented.

There are guidelines being developed today in order to address triage in this situation—-taking some patients off ventilators in order to make room for others. (and if a panel has come up with this guideline?). Those patients removed from mechanical ventilation will have to be given enough medicine to relieve the resultant distress and suffering. I am not making this up or advocating it, it’s what on the disaster menu.

Sounds like the subplot for a movie.

Again I feel that this particular incident should be handled by a Truth Commission of sorts. Grant immunity from prosecution for all, grant immunity from professional licensure revokation to all, a fund to handle any civil claims. Then elicit a full and truthful (as can be) accounting from all involved. Use such to analyze, come up with lessons and guidelines.

The other aspect of this story which I find interesting is the cascade of false (racist) rumors which were then whipped up and seized upon predictably by certain types of personalities. If you watch “The Office” I’m speaking about the character played by Rain Wilson—Dwight Schrute. When a major disaster strikes the Dwight Schrutes come out of the woodwork. You know the kind..they get a warm fuzzy feeling when they talk about how there were summary executions during the SF 06 Earthquake for looters.

In Ms. Finks article there was a consistent thread of “Schrutism” running through.

Jeff Whitnack: I noticed the same thing—to the point that the response was what I would call “overdetermined,” or as much the result of the staff’s fears stoked by certain individuals, as it was
required by actual objective circumstance. The fact that doctors were traipsing around with guns, and rejecting as “denialism” the efforts of others to maintain normal routine treatment as much as possible, is a sign that this is exactly what happened.

As another commenter noted, this was the only hospital out of several similarly affected in which anything so horrible happened. That, right there, is a powerful sign that organizations and people failed at Memorial. Perhaps focusing on what other hospitals did to avoid the result at Memorial would be a more useful exercise, which would also, happily, undermine Dr. Pou’s claim to insight as an expert in lifeboat medical ethics.

Just as the staff in this hospital made decisions without consulting those under their care - or others who might have held differing opinions - Dr.Fink points out that the U.S. medical community is proceeding with developing protocols for patient care during a disaster without consulting the public they serve.
Thank you, Dr. Fink, for bringing this important issue to light in such a powerful and profound way. Hopefully your hard work will pay off in provoking greater public debate about these protocols before decisions are made that have the potential to affect all of us.

Did Dr. Fink point that out as regards disaster preparedness? I must have missed that.

I don’t know what the mechanism would be for “consulting the public they serve” as regards disaster preparedness, in the context especially of resource allocation and re-allocation per triage. Would this be a bill in Congress, state referendums, etc. Is there any way that some bill or referendum would ever be anything other than a muddled document which wouldn’t cover all the bases anyway?

There is a response from Dr. Pou’s attorney to the recent NY Times article.

Lots of slippery slopes. Dr. Pou was charged with murder and then reacted with a combination Legal and PR campaign (as would anybody). Then there is ongoing civil matters as well. But it’s probably another in a series of slippery slopes as she then gets invited to speak as a “Poster Child” for disaster response (a whole cottage industry and don’t get me started on that!).

Don’t get me wrong—I think Dr. Pou probably has a lot of valuable information and experience to impart….but not necessarily as an expert but rather more as an “Accidental Tourist”. And it needs to be done with full and open information—something not possible for her now.

Kudos to Dr. Fink for taking on this complex piece of investigative reporting. I’m not sure what I find more shocking: the decisions made at Memorial, or the response among many that these doctors and nurses be “left alone” and lauded as heroes for their actions.
I was a physician at Charity Hospital during Katrina, and I am still struggling to understand WHY the situation at Memorial became what is described in this article. In the many meetings among our hospital staff during that difficult week (we actually had regular meetings every four hours), there was never any discussion or even thought that we would stop treating patients medically, administer lethal doses of medication, or leave before every patient was evacuated alive. Only two patients out of hundreds of patients died during that week—-unlike the nearly 1 out of every 4 who perished at Memorial.
What were the circumstances that led to such different outcomes? The conditions at Charity were not better—in fact, our generators failed two days earlier (Monday Aug 29th) and the hospital was not evacuated until a day after Memorial (Friday). Nor were the patients less acutely ill—since Charity was a Level One Trauma Center, the patients were actually the “sickest of the sick” and included many ventilator-dependent ICU patients and people with end-stage AIDS. Certainly, revisiting the situation in the hospitals during this disaster is important so we can identify the mistakes, and so we are not doomed to repeat them.
It is absurd for people to suggest that in such difficult conditions, doctors and nurses are beyond scrutiny and should not be held accountable for their actions. Yes, I hold many government officials responsible for the atrocious lack of response. I am angry that my patients had to wait nearly a week in inhumane conditions while we tried to practice medicine in a very basic way. But I am also furious when I read statements from Dr. Cook that he “couldn’t imagine” the staff carrying down nine patients from the 5th floor. There is a saying in medicine that you should treat the patient as you would treat a family member. It may be trite, but if Mr. Everett was your father or son or brother, who among us would not do everything possible to bring him down the stairs to waiting rescue? We had several paralyzed patients on my floor, and even a nearly 400 lb man with a broken hip in the hospital—I cannot imagine leaving them behind, or “hastening” their deaths.
It seems like Drs. Cook and Thiele at least, and maybe others at Memorial, feel comfortable with what happened. The rest of us, however, will continue to be haunted by the horrific events there. I can only hope my residents and medical students will read such accounts in order to learn about how, during a disaster, human compassion can deteriorate so quickly.

If there ever were to be a “Truth Commission” of sorts—-and perhaps the culmination of courtroom and media exposure will provide us all with a delayed and convoluted version of such—-it would be a good idea to compare and contrast the differences between Charity and Memorial, and other local hospitals during the disaster.

One thing that strikes me is that, after reading the story by Fink, the very idea of there being Q4 Meetings at Memorial strikes one as both necessary and bizarre at the same time. Bizarre both in the sense of logistics and in that the group mindset or “leadership” had already set a far different tone. But very necessary almost as akin to a surgical pause. But a different tipping point had already occurred at Memorial.

I am reminded a bit of the “banality of evil” when Eichman’s trial was described. This is another step removed in that the banality of whatever evil took place lacks any ideological foundation. It was just a change in workflow.

At Memorial the impression I get is of a dual scenario—- rats deserting a sinking ship and musical chairs. Dr. Pou got left without a chair and “holding the bag”.

Well the comments have winded down, but something to add. I just happened to be watching the movie “The Mist”, based on a Stephen King short story. It has many themes similar to this topic. A mist is generated as part of a rip in the universe, allowing many ravenous creatures to come across. Scores of people are trapped in a supermarket and fighting for survival or escape. The religious zealot who gets the mob riled up could be compared to the Dwight Schrute influence…the closing scene could be augmented by the father being arrested….then there is the dialogue at 1 hour 12 minutes in…

‘‘How long should health care workers have to be with patients who may not survive?’’ This is one question that boils my blood. At first, I hated this lady by the name of Ana Pou… how dare she take people’s lives into her own hands? Act as if she is God? But my faith will not let me give her that much of my energy! Romans 12:19 is all that I can think of when any stories arise about this “supposed” doctor Ana Pou. She has the nerve to get laws passed that would justify her acts in 2005. She never said she didn’t euthanized anyone, she just replies, she ‘‘helped’’ patients ‘‘through their pain.’’ Yes, she helped the DNR patients through their pain… just like veterinarians help wounded animals when they are in pain. She DNR-ed those patients (not Do Not Resuscitate… She Did Not Rescue). She made a decision that will FOREVER be with me and my family (especially my aunt who had to leave my grandmother’s side)!!! She Did Not Rescue my grandmother!!! She “helped” my grandmother “through her pain.” By “helping” my grandmother, I no longer have a grandmother. She is home with my Father and grandfather! The day I have to say RIP Wilda Faye Sims McManus is on September 1, 2005… who knows what day or time she actually went into eternal sleep, due to the lethal cocktail Ana Pou and those two nurses injected my grandmother with? She will get hers in the end… Vengeance is not mine, it’s the Lord’s! I pray for my family and the other families who lost a family member during this time… my heart goes out to you!

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